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Best Practices in Documentation for Rehab Providers
Documentation is a critical component of therapy services. Your documentation is used to communicate with other healthcare professionals, evaluate the effectiveness of treatment, and substantiate billing by justifying the care provided. Individuals who review your documentation in the medical record will never see the therapy sessions, so you have to “tell the story” by including the necessary components to justify services for reimbursement. This course covers general guidelines for documentation, components to improve documentation, and special considerations. Practical examples are provided to help you incorporate best practices into your documentation.
Identify five required components of therapy goals.
Determine at least three ways to improve documentation through the use of evidence-based practice and demonstration of skilled need and medical necessity.
Recall at least four documentation requirements across all settings.
IV Therapy Complications
Nurses deliver infusion therapy to millions of patients in hospitals, home healthcare settings, long-term care facilities, outpatient clinics, and physicians’ offices annually. Nursing professionals perform many daily activities involving peripheral catheter insertion and safe delivery of intravenous (IV) fluids and medications. The use of vascular access devices and IV therapy are commonplace in the acute care setting. With that said, clinicians must take caution due to the potentially serious and fatal complications that can occur from inappropriate IV fluid or drug delivery. Patient safety requires that nurses institute safeguards to avoid complications associated with IV treatment.
Discuss the maintenance and complications of peripheral IV (PIV) therapy.
Identify drugs that can cause tissue damage if extravasation occurs.
Recall the components for documenting a peripheral IV insertion.
Management of Needlestick Injuries
Needlestick injuries continue to pose a threat to all healthcare professionals (HCPs). While HIV was once the most concerning organism, today, hepatitis B and C take precedence (King & Strony, 2022). Regardless of circumstances, more than 90% of sharps injuries are preventable (International Safety Center [ISC], n.d.). Therefore, all healthcare clinicians must be diligent to avoid injury even in busy and stressful working conditions. This module will review the current literature on managing the most common bloodborne pathogens (BBP) transmitted by needlestick injuries and evaluating post-exposure prophylaxis.
Discuss procedures to follow after a needlestick or sharps injury.
Identify factors that can lead to a needlestick or sharps injury.
Identify factors that can prevent a needlestick or sharps injury.
The Impact of Psychedelics
This course will provide healthcare professionals in the acute care setting with an introduction to the use of psychedelics for the treatment of behavioral health conditions. Healthcare professionals will learn about the types of agents used, their indications, benefits, and their associated risks and side effects.
The goal of this course is to provide health care professionals in the acute care setting with an introductory review of novel therapeutic agents used to treat behavioral health conditions.
Recall how psychedelics are used to treat behavioral health disorders and how they impact symptoms of behavioral health disorder.
Identify the potential risks and side effects of psychedelics.
Recognize whether an individual is a good candidate for psychedelic treatment for behavioral health symptoms.
Central Arterial Aneurysms: Types and Management
Aneurysms can be deadly and can come on suddenly. Knowing what to do to help your patient with an aneurysm could be the difference between life and death for them. Early detection and management are the best tools to prevent a fatal outcome. Healthcare professionals should know what an aneurysm is, which of their patients are at highest risk, the signs and symptoms of an aneurysm, and how to manage an emergency rupture. This course focuses on central arterial aneurysms of the abdominal and thoracic aorta.
Recall concepts associated with vascular physiology and types of aneurysms.
Recognize clinical manifestations of central arterial aneurysms and associated risk factors.
Apply common techniques for managing patients with abdominal and thoracic aneurysms, pseudoaneurysms, and dissections.
CEN: Respiratory Emergencies
The Certified Emergency Nurse (CEN®) is required to demonstrate competency in the domain of emergency nursing which includes knowledge of respiratory emergencies, their signs and symptoms, their management, and the nursing interventions.
The goal of this course is to review the knowledge domains specific to respiratory emergencies included as a part of the Certified Emergency Nurse (CEN®) exam.
This course is not affiliated with the Board of Certification for Emergency Nursing (BCEN).
Identify signs and symptoms of life-threatening respiratory illnesses and injuries.
Analyze strategies to manage respiratory conditions and emergencies that present to the emergency department.
CEN: Maxillofacial and Ocular Emergencies
The Certified Emergency Nurse (CEN®) is required to demonstrate competency in the domain of emergency nursing which includes knowledge of maxillofacial and ocular emergencies, their signs and symptoms, management, and applicable nursing interventions.
The goal of this course is to review the knowledge domains specific to maxillofacial and ocular emergencies included as a part of the Certified Emergency Nurse (CEN®) exam.
This course is not affiliated with the Board of Certification for Emergency Nursing (BCEN).
Identify signs and symptoms and the management of life-threatening maxillofacial illnesses and injuries.
Analyze strategies to manage ocular conditions and emergencies.
CEN: Medical Emergencies
The purpose of this program is to inform the emergency nurse of medical emergencies, including a comprehensive assessment and appropriate intervention.
Identify signs and symptoms of medical conditions and injuries.
Describe a comprehensive plan for the care of medical conditions including diagnostic and treatment interventions, and patient education.
CEN: Orthopedic and Wound Emergencies
The purpose of this program is to inform the emergency nurse of common orthopedic emergencies, including a comprehensive assessment and appropriate interventions.
Identify signs and symptoms of orthopedic and wound emergencies.
Describe a comprehensive plan for the care of orthopedic and wound emergencies including diagnostic and treatment interventions, and patient education.
CEN: Professional Issues in Emergency Nursing
The purpose of this program is to describe the impact of professional practice issues as they relate to the emergency nurse, their patients, and the health care system.
Recognize vulnerable patient populations and sensitive care situations facing emergency nurses.
Identify professional practice issues across the health care system that support high-quality patient care and satisfaction.
Wellness Strategies that Support Addiction Recovery
Substance use is linked to millions of deaths worldwide each year (Ritchie & Roser, 2019). Supporting individuals’ long-term recovery from substance use can help save lives. Recovery is a lifelong process that aims to keep an individual substance-free while improving their overall quality of life. Wellness strategies enhance recovery outcomes by focusing on optimal health across all dimensions of an individual’s life.
Discuss how wellness approaches can positively impact recovery from substance use disorders.
Recognize the eight dimensions of wellness.
Identify wellness strategies to facilitate long-term recovery from substance use disorders.
Septic Joint: Diagnosis and Treatment
Septic arthritis is caused by infection and inflammation in the joint and can result in significant damage to the joints. Early recognition and treatment are critical to the preservation of joint function. This course will discuss how to quickly identify and treat septic arthritis.
The goal of this course is to provide physicians, nursing professionals, and radiologic technologists with information about septic arthritis.
Recall how septic arthritis is acquired and its typical presentation.
Identify the laboratory and radiological tests used to make a diagnosis of a septic joint.
Recognize the principles of septic joint treatment.
CEN: Psychosocial Emergencies
The Certified Emergency Nurse (CEN®) is required to demonstrate competency in the domain of emergency nursing which includes knowledge of psychosocial emergencies, their signs and symptoms, their management, and the nursing interventions that are needed.
The goal of this course is to review the knowledge domains specific to psychosocial emergencies included as a part of the Certified Emergency Nurse (CEN®) exam.
Recognize signs and symptoms of specific psychosocial emergencies.
Identify strategies to manage psychosocial emergencies.
An Update on Bariatric Surgery
The goal of this course is to equip nurses in the acute care setting with knowledge of the different bariatric surgical options and the psychosocial, metabolic, and physiological issues that patients may encounter before and after bariatric surgery.
Recall the different bariatric surgical options available for patients with obesity.
Identify psychosocial and quality-of-life issues affecting patients before bariatric surgery.
Recognize metabolic, physiological, and psychological changes that can occur in patients after bariatric surgery and the role nurses have in their care.
Bowel Ischemia, Perforation, and Obstruction
Bowel ischemia, infarctions, perforations, and obstructions are serious conditions that require prompt recognition and interventions to prevent severe complications and death. There are several underlying conditions that predispose patients to these conditions, for which education and risk modifications are crucial.
The goal of this course is to equip nursing professionals in acute care with knowledge of risk factors, signs and symptoms, and management strategies for bowel ischemia, infarction, perforation, and obstruction.
Identify anatomical and physiological aspects of the intestines associated with bowel ischemia, infarctions, perforations, and obstructions.
Describe risk factors, causes, signs/symptoms, management, treatment, and complications of bowel ischemia, infarctions, perforations, and obstructions.
Multiple Sclerosis: Treatment and Care Considerations
It is estimated that there are more than 2.8 million people worldwide living with multiple sclerosis (MS). In the United States, there are almost 1 million people living with the disease (National Multiple Sclerosis Society [NMSS], 2020). MS is a chronic, progressive autoimmune disease of the central nervous system (CNS) caused by damage to the protective myelin sheath covering neurons. MS lesions, or plaques, disrupt electrical impulses from neurons in the CNS to muscles that can affect mobility, elimination, energy, vision, and other functions (DynaMed, 2022).
Recall the overarching disease pathophysiology and main symptoms with discernable interventions of MS.
Identify the disease classifications and the diagnostic algorithm, including the McDonald Criteria for MS.
Review therapeutic approaches for treating the underlying disease of MS.
Documentation: The Legal Side
As a professional nurse, you are expected to be familiar with many aspects of care. You are not exempt from malpractice or negligence claims because you were following orders. You are responsible for assessing, planning, implementing, and evaluating appropriate nursing care. What you document can and does reflect the care provided and the outcomes of that care. Documentation that is factual, complete, timely, and detailed is required. In this course, you will learn about concepts and rules regarding documentation in the medical record. Legal aspects to be aware of while practicing will also be discussed. The goal of this course is to educate nursing professionals in post-acute care settings about the legal implications of documentation.
Discuss malpractice, negligence, and compensatory and punitive damages as they relate to healthcare. Explain four intentional torts that a healthcare professional may be held liable for. Describe four documentation techniques to use to avoid legal issues.
Managing Peripheral Artery Disease
The goal of this course is to provide the clinician with up-to-date best practices for identifying and treating patients with PAD. It includes symptoms, complications, risk factors, and modifications of PAD. In addition, diagnostic tests, assessment, and treatment strategies will be discussed.
Identify risk factors and complications related to PAD.
Discuss two assessment findings and tools used to diagnose PAD.
Describe two disease management and education techniques for patients with PAD.
Assessment and Treatment of Depressive Disorders in Children & Adolescents
In this course, you will learn to identify different depressive disorders, as well as the unique ways depression manifests in children and adolescents. Additionally, you will learn to recognize risk factors for both depression and suicidality in youth.
An integrated care model treats the whole child by combining primary care and mental healthcare in one setting. Within this model, treatment providers understand how to screen for depression and suicidality in order to coordinate care. You will learn about specific instruments useful for detecting depression and suicidality among youth. An understanding of the root causes of depression will highlight the rationale for various treatment approaches. Lastly, you will be able to describe the best practices available to help children and adolescents manage depression.
Identify three different types of depressive disorders and common symptoms of depression in children and adolescents.
Identify at least five causes and risk factors of clinical depression and how to screen for depressive disorders in children and adolescents.
Describe three interventions to treat child and adolescent depressive disorders.
Stroke Care: From Onset to Rehab
This course provides a comprehensive understanding of stroke care from onset to rehab. Details of stroke care in the acute care setting and rehabilitation for stroke are reviewed. Stroke prevention strategies are explained.
Apply knowledge of assessment, diagnosis, and treatment for stroke in the hyperacute and acute phase.
Identify secondary prevention strategies, including lifestyle changes and drug therapies.
Recall interventions for rehabilitation from stroke in the acute and post-acute setting.
Weight Loss Medications: A Comprehensive Review
When lifestyle modifications such as improving nutrition and increasing physical activity do not achieve adequate weight loss, pharmacotherapies may be needed. Pharmacotherapy is used as a supplement to lifestyle modifications and should only be implemented in patients who meet certain criteria and have a need to reduce their risk of obesity-related comorbidities. This course will review candidate criteria for weight management drugs, which drugs have been approved by the Food and Drug Administration (FDA), and their safety or effectiveness. It will also review dietary supplements used for weight loss and the lifestyle behaviors needed to increase the efficacy of pharmacotherapies. The goal of this course is to educate the healthcare team in the acute care setting on weight loss medications.
Indicate the criteria for weight loss drug therapy in patients affected by obesity.
Recognize the safety and effectiveness of prescription drugs and devices, and dietary supplements used for weight loss.
Recall lifestyle behaviors that are needed in conjunction with weight loss drugs, devices, and supplements.
Anesthesia: Perioperative
The perioperative nurse plays a primary role in the anesthesia experience. Knowledge of techniques, patient assessment, and care management for the patient receiving or recovering from anesthesia positively impacts patient outcomes. This course discusses anesthetics and adjuvant medications used in the perioperative setting, anesthesia-related complications, and the nurse’s role in assisting with anesthesia management.
This course provides nursing professionals with information about the principles and practices of anesthesia care in the perioperative setting.
Identify the stages and types of anesthesia, and associated medications commonly used in the perioperative setting.
Recognize important assessment areas and nursing interventions for the perioperative patient receiving or recovering from anesthesia.
Describe complications of anesthesia and their treatments.
Medical Management of Operative/Assisted Vaginal Delivery
This course discusses best practices in operative vaginal delivery techniques—forceps-assisted delivery and vacuum-assisted delivery (OAVD), as well as episiotomy.
The course is case-based, so you will have an opportunity to apply the principles covered to particular patient scenarios. The cases are branched, with different outcomes based on different choices.
Use of OAVD techniques vary from organization to organization. You may, for example, work in a hospital in which forceps techniques are no longer taught to residents. Each section has been organized so that you can move through it quickly or delve into it more deeply, depending on its relevance to your clinical practice.
Discuss the steps, indications, contraindications, and potential complications associated with vacuum-assisted vaginal delivery, forceps-assisted vaginal delivery, and episiotomies.
Describe the circumstances in which an episiotomy is and is not an appropriate intervention.
Explain the importance of the flexion point when placing a vacuum cup and how it is located. Identify the criteria for correct placement of the forceps during a non-rotational delivery, as well as guidelines regarding the number of pulls.
Perioperative Series: Emergencies in the OR
Perioperative providers can BEST prepare for emergencies in the operating room by knowing the responsibilities of each team member and rehearsing interventions ahead of time. When you are in the moment and your heart is racing, it’s easy to forget how to respond or even where supplies are located. Practicing your responsibilities and team interventions ahead of time will help to prepare you for the unexpected. This course provides you with an opportunity to participate in five emergency scenarios to test your knowledge. Time is of the essence when an emergency happens so you must think and act fast to save the patient!
The goal of this course is to equip nurses and STs with knowledge of the responsibilities of the team during a range of OR emergencies.
Recognize evidence-based strategies for treating and preventing a range of OR emergencies.
Describe the roles and responsibilities of members of the surgical team when emergencies occur.
Recall the best practices for improving patient outcomes during an emergency.